Provider Demographics
NPI:1053947192
Name:ANDERSON, MARY PARKS (RN, CRNA)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:PARKS
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:RN, CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 BARKSDALE ST
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29649-2001
Mailing Address - Country:US
Mailing Address - Phone:770-301-6719
Mailing Address - Fax:
Practice Address - Street 1:1325 SPRING ST
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:SC
Practice Address - Zip Code:29646-3860
Practice Address - Country:US
Practice Address - Phone:864-725-4111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-20
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC23951367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered